Noridian Healthcare Solutions, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction D, has released the quarterly results of its service-specific prepayment reviews for LSO codes L-0631 and L-0637, knee orthosis code (KO) L-1833, and AFO codes L-1960, L-1970, and L-4360 from March through June. Based on the quarterly results, Noridian said it will continue the reviews.
The quarterly results are as follows:
LSOs
- The L-0631 (LSO sag-coro rigid frame pre) review involved 172 claims, of which 171 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99 percent.
- The L-0637 (LSO sag-coronal panel prefab) review involved 160 claims, of which 152 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99 percent.
- The top reasons for denial are:
- Documentation does not support that modifications were made for the custom-fitted item.
- Documentation was not received in response to the additional documentation request (ADR) letter.
- Proof of delivery (POD) is incomplete or missing elements.
- Documentation does not support coverage criteria.
KO
- The L-1833 (KO) adj jnt pos r sup pre ots) review involved 511 claims, of which 462 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 92 percent.
- The top reasons for denial are:
- Documentation does not support knee instability.
- Documentation was not received in response to the ADR letter.
- POD is incomplete or missing elements.
- International Statistical Classification of Diseases and Related Health Problems tenth revision (ICD-10) code was missing or invalid.
AFOs
- The L-1960 (AFO pos solid ank plastic mo) review involved 176 claims, of which 129 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 73 percent.
- The L-1970 (AFO plastic molded w/ankle j) review involved 300 claims, of which 237 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 78 percent.
- The L-4360 (Pneumati walking boot prefab) review involved 425 claims, of which 414 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 98 percent.
- The top reasons for denial are:
- Documentation does not support that modifications were made for the custom-fitted item.
- Documentation was not received in response to the ADR letter.
- Documentation does not support medical necessity of a custom-fabricated rather than prefabricated orthosis.
- POD was not received.
